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'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. File Original with DWR State of California DWR Use Only—Do Not Fill In Well Completion Report Page Of Refer to Instruction Pamphlet State Well Number/Site Number Owner's Well Number No. e0362552 N w Date Work Began 12/29/2017 Date Work Ended 1/19/2018 Latitude Longitude Local Permit Agency San Joaquin Health Dept. Permit Number 37740 Permit Date APN/TRS/Other Geologic Log Well Owner Orientation @Vertical @Horizontal @Angle Specify Name Marie Baretta Drilling Method mud rotary Drilling Fluid Fresh Water Mailing Address 28877 S.Chrisman Rd. Depth from Surface Description Tracy CA 95304 Feet to Feet Describe material rain size,color,etc Cit State_Zi 0 1 topsoil Well Location 1 20 clay Address 28877 S. Christman Rd. 20 40 sand/gravel City Tracy County San Joaquin 40 44 clay Latitude N Longitude _yv 44 64 sand/gravel Dec Min. Sec. Dea Min. Sec. 64 74 Clay Datum Dec.Lat. Dec.Long. 74 76 sand/gravel APN Book 253 Page 220 Parcel 05 76 101 Clay Township -Range Section 101 108 sand/gravel Location Sketch Activity Sketch must be drawn by hand after form isprinted.) Q New Well 108 139 clay North Q Modification/Repair 139 144 sand/gravel O Deepen 144 150 clay O Other ravel Q Destroy 150 154 sand/ gravel Descnce procedures and matenals 154 167 clay ender'GEOLOGIC LOG' 167 180 sand/gravel Planned Uses 180 184 clay Water Supply 184 186 sand/gravel _ [Z]Domestic ❑Public 186 217 clay w Lu ❑Industrial Q Cathodic Protection 217 232 sand/gravel Q Dewatering 232 245 clay Q Heat Exchange 245 247 sand/gravel Q Injection 247 251 clay with gravel streaks Q Monitoring 251 300 clay Q Remediation Q Sparging 1? ITC FISTA 1) SouthQ Test Well Illustrate or describe distance of well from roads,buildings,fences, Q Vapor Extraction overs.etc.and attach a map Use additional paper II necessary. Q Other MAR 118 t Please be accurate and complete Water Level and Yield of Completed Well F'IN I RO N N1 F'NTA 1, 11 F. i 1,1 i 1 Depth to first water (Feet below surface) Depth to Static DEP RlF FIN I FN " Water Level 61 (Feet) Date Measured Total Depth of Boring 300 Feet Estimated Yield' (GPM) Test Type Total Depth of Completed Well 251 Feet Test Length (Hours) Total Drawdown (Feet) "May not be representative of a well's long term yield. Casings Annular Material Depth from BoreholeType Material Wall Outside Screen Slot Size Depth from Surface Diameter Thickness Diameter Type If Any Surface Fill Description Feet to Feet Inches Inches Inches (Inches)_ Feet to Feet 0 120 14 Blank PVC .322 8 0 200 quik grout 120 220 14 Blank PVC .410 8 200 251 No 6 sand 220 251 14 Screen PVC .322 8 0.050 1 1 1 11 i I --I— i I_I_I ----F J Attachments Certification Statement ❑ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief ❑ Well Construction Diagram Name Hennings Bros Drilling Co Inc Person,Firm or Corporation ❑ Geophysical Log(s) 1930 Ladd Rd. Modesto CA 95356 ❑ Soil/Water Chemical Analyses Address City State zip ❑ Other Signed 02/01/2018 290813 Attach additional informationif it exists. C-5f L used Water Well Co actor Date Signed C-57 License Number DWR 188 REV.1/2006 IF ADDITIONAL SPA E IS NEEDED,USE NEXT CONSECUTIV NUMBERED FORM